1. EXTREMITY TRAUMA Instructor Name: Title: Unit:

2. OVERVIEW Relationship of extremity trauma to assessment of life-threatening injury Types of extremity injuries Assessment & management –General Estimation of blood loss Splinting –Specific injuries

3. FRACTURE PRIORITIES Fractures rarely life-threatening Perform BTLS Primary Survey to find life- threatening injuries –Do not be distracted by obvious but not life- threatening extremity injuries –Be alert to major bleeding from extremity injuries

4. TYPES OF FRACTURES Open –Bone ends protrude through the wound –High risk of infection Closed –No opening through the skin Fractures may –Damage adjacent nerves and vessels –Produce severe bleeding –Blood loss may be internal

5. DISLOCATIONS Joint deformity may be fracture or dislocation Can cause neurovascular compromise of distal extremity Always assess –Distal sensation –Distal motor function –Distal pulses and skin color

6. AMPUTATIONS Control bleeding by direct pressure –Tourniquets rarely needed Locate amputated part Do not place amputated part directly in ice or water –Place part in plastic bag –Place bag in ice-water mixture

7. SPRAINS & STRAINS Signs similar to fractures X-rays needed to distinguish from fractures Treat as if fractured “If an extremity hurts, immobilize it”

8. OPEN WOUNDS Control bleeding with pressure –Tourniquets rarely needed Check distal PMS –Pulse –Motor –Sensory COURTESY ROY ALSON M.D.

9. Applying Tourniquet

10. IMPALED OBJECTS Stabilize in position found –Removal may cause uncontrollable bleeding Exceptions –Object in cheek –Cannot control major bleeding with object in place

11. COMPARTMENT SYNDROME Early –Pain –Paresthesias Late –Pallor –Pulselessness –Paralysis Pathophysiology Signs and symptoms

12. SIGNS & SYMPTOMS OF EXTREMITY INJURY Pain Deformity Swelling Loss of movement Crepitus COURTESY ROY ALSON, M.D.

13. ASSESSMENT Scene Size-Up –Clues to specific injuries BTLS Primary Survey –Pelvic fractures or bilateral femur fractures are Load & Go –Control major bleeding –History may suggest other injuries

14. BLOOD LOSS FROM FRACTURES Pelvis - 500cc for each break –May lacerate major vessels causing major internal bleeding Femur - 1000cc Multiple fractures can produce life- threatening hemorrhage –May all be internal

15. DETAILED EXAM CHECK EXTREMITIES FOR Deformities Contusions Abrasions Penetrations Burns Tenderness Lacerations Swelling ALSO CHECK FOR PMS

16. MANAGEMENT SPLINTING –Decreases pain –Prevents further injury –Decreases blood loss COURTESY DAVID EFFRON, M.D.

17. GENERAL RULES OF SPLINTING Visualize injured part Check and record PMS before and after splinting May apply gentle in-line traction Cover open wounds with sterile dressings Pad the splint Immobilize one joint above and below the site of the injury

18. GENERAL RULES OF SPLINTING Do not push bone ends back under the skin May apply splints en route to the hospital If in doubt, splint Never delay transport of critical patient to perform splinting of minor fractures

19. MANAGEMENT LOAD & GO PATIENTS Spinal immobilization –Long backboard –C-collar –Head immobilizer Limit splinting until en route Backboard acts as “whole body” splint

20. MANAGEMENT SPECIFIC INJURIES CLAVICLE FRACTURES –Common injury –Apply sling & swathe

21. SHOULDER INJURIES AC separation –Sling & swathe Shoulder dislocation –Use pillow with sling & swathe Fracture –Use sling & swathe

22. ELBOW INJURY Fracture or dislocation may cause neurovascular injury Splint in position found Transport promptly

23. FOREARM/WRIST INJURY Rigid splint –Keep hand in position of function Air splint –May be difficult to reassess circulation Pillow

24. FEMUR FRACTURES High force injury High potential for shock May use traction splint PASG or air splint may give adequate stabilization COURTESY OF ROY ALSON M.D.

25. KNEE FRACTURE OR DISLOCATION Orthopedic emergency Frequently causes vascular injury Dislocation associated with high incidence of leg amputation

26. MANAGEMENT KNEE DISLOCATION Obvious dislocation without distal pulse –Apply gentle in-line traction If gentle traction does not restore the pulse –Splint in place Prompt transport

27. TIBIA-FIBULA FRACTURES Frequently open fractures Significant hemorrhage possible Dress open wounds Depending on level of fracture –Upper - Rigid splint –Lower - Air splint or pillow COURTESY OF ROY ALSON M.D.

28. FOOT OR HAND INJURIES Common industrial injury Often disabling Rarely life-threatening Splint foot with pillow Splint hand in position of function

29. SUMMARY Note mechanism of injury Remember priorities –ABCs first Be prepared for shock Record PMS

30. SUMMARY Critical patients –Do not waste time on minor splinting –Immobilize spine –Apply other splints en route Immobilize one joint above and below If in doubt, splint

31. QUESTIONS?